Evaluation of Performance of Anesthesia Assistants of Nepal

Transcription

1 Evaluation of Performance of Anesthesia Assistants of Nepal Submitted to: Nepal Safer Motherhood Project Submitted by: M&M Associates 63-Kirtan Marg, Bishalnagar Kathmandu, Nepal Phone:

2 Table of Contents i. Acronyms and Abbreviations 2 ii. Preface 3 iii. Study Team 4 iv. List of Tables and Charts 5 v. Executive Summary 6 A. Introduction Anesthesia Assistant Program in Nepal Literature Review Objectives of the Study Methodology Limitations of the Study 22 B. Findings Profile of the respondents Quality of AA training Competence of trained AAs Capacity of CEOC Hospitals in providing quality anesthesia services General Working Environment, and, Enabling and Hindering Factors Estimated number of AAs required 60 C. Conclusions and Discussions 61 D. Recommendations 65 E. Appendices Structured IDI Questionnaire for AA 2. Structured Test Questionnaire for AA 3. Skill Assessment Checklist for AA 4. Checklist for equipment and drugs used for surgery

3 i. Acronyms and Abbreviations AA - Anesthesia Assistant AAT - Anesthesia Assistant Training AHW - Auxiliary Health care provider ANM - Auxiliary Nurse Midwife BEOC - Basic Emergency Obstetric Care CEOC - Comprehensive Emergency Obstetric Care CSF - Cerebrospinal Fluid DFID - Department for International Development DOHS - Department of Health Services FHD - Family Health Division GA - General Anesthesia HA - Health Assistant HMCM - Hospital Management Committee Member INF - International Nepal Fellowship IV - Intra-venous IVA - Intra-venous Anesthesia LSCS - Lower Segment Cesarean Section MDGP - Doctorate in Medicine in General Practice MOH - Ministry of Health NHTC - National Health Training Centre NSMP - Nepal Safer Motherhood Project OT - Operation Theater PA - Physician Anesthetist SN - Staff Nurse WHO - World Health Organization M&M Associates 2

4 ii. Preface The National Safe Motherhood Policy of the Ministry of Health envisages the provision of CEOC services in all peripheral hospitals of the country. This means the availability of 24- hour emergency services including surgery. The importance of proper anesthesia administration during surgeries cannot be overstressed. Realizing the importance of anesthesia services, the Ministry of Health, in partnership with the World Health Organization initiated a three month Anesthesia Assistant training in Bir Hospital in The Family Health Division conducted a follow up on the training with a few trainees and received enough feedback suggesting that the curriculum needed to be revised. In partnership with Nepal Safer Motherhood Project, the Family Health Division piloted a competency based 6 months training curriculum in three districts. This work was led by Dr. Paul Foster of the International Nepal Fellowship as part of their Health Services Partnership Project, who developed the course and conducted most of the training. The initial curriculum was revised after the pilot test, and developed into the Competency Based Training Course for Anesthesia Assistants in Nepal. The curriculum has been endorsed by the National Health Training Center. The training program is currently being conducted in Patan Hospital and Tansen Hospital. This study attempts to evaluate the six months anesthesia assistant training curriculum, the trainees' perception and suggestions for future improvement, the knowledge and competence level of the Anesthesia Assistants, the anesthesia services being provided and the perceptions of the doctors working with Anesthesia Assistants, the peers of Anesthesia Assistants and the Hospital Management Committee Members. The study attempts to explore some of the related issues on the Anesthesia Assistant training, the services of Anesthesia Assistants, and the impact of Anesthesia Assistants services on the overall services of the hospital. The study was designed jointly by Mr. Ashish OM Sitoula, Dr. Charles Collins, Dr. Samson Retnaraj, Dr. Pius Raj Mishra and Dr. C. A. K. Yesudian. The clinical evaluation tools were based on the Training Guides developed by Dr Paul Foster. The study team would like to thank all the respondents of the study for availing their valuable time in replying to the queries and in supplying the required information that has made this evaluation possible. Special thanks are due to the Medical Superintendents of the all hospitals evaluated, for facilitating the data collection process. Likewise, sincere appreciation is extended to the following for their guidance in shaping the study: Dr. Yeshobardhan Pradhan, Dr. Ganga Shakya and Dr. Bimala Lakhey, FHD; Dr. Baburam Marasini, NHTC; Dr. Vijaya Manandhar, WHO; Dr. B. D. Jha and Dr. Resham Rana, Bir Hospital; and Dr. Maurice Lee, INF. The study team would like to place on record its gratitude to Ms. Alison Dembo Rath, Dr. Indira Basnet and the NSMP team for entrusting the study to M&M and providing the required guidance during the entire course of the study. M&M Associates M&M Associates 3

5 iii. Study Team Mr. Ashish OM Sitoula - Team Leader Dr. Charles Collins - Technical Specialist in Anesthesia Dr. Samson Retnaraj - Technical Specialist in Anesthesia Dr. Pius Raj Mishra - Senior Researcher Dr. C. A. K. Yesudian - Advisor Mr. Anand K.C. - Enumerator Ms. Niraja Shakya - Enumerator Ms. Parbata Acharya - Enumerator Ms. Achala Shrestha - Enumerator Mr. Binit Pandey - Research Assistant Mr. Nishes Mishra - Research Assistant M&M Associates 4

6 iv. List of Tables/Charts List of Tables Table 1 Table 2 Table 3 Table 4 Table 5 Table 6 Table 7 Table 8 Table 9 Table 10 - Designation of AAs in the hospitals - Designation of doctors - Perception of AAs on different aspects of training - Responsibility of AAs - AAs' practice of record keeping - Number of surgeries conducted - Distribution of types of surgeries - AAs' perception on surgeon's level of confidence while providing service - Current designation of AAs in the hospitals - Number of surgeries conducted List of Charts Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Figure 8 Figure 9 Figure 10 Figure 11 Figure 12 Figure 13 - AAs' satisfaction from training - Quality of training materials - Duration of training - AAs' perception on technical level of training - AAs' confidence level after training - Knowledge level of AAs - Pre-operative evaluation of patients - AAs' practice of visiting patients after surgery - Surgeons level of confidence on the skills of AAs - Awareness of existence of job description - Job satisfaction of AAs - Working relationship of AA with surgeons/doctors - Working relationship of AAs with peers/colleagues M&M Associates 5

7 v. Executive Summary In 1996, a three-month anesthesia assistant course was launched with financial support from World Health Organization. The Department of Anesthesia of Bir Hospital was selected as a training site, and in four years, and approximately 50 Anesthesia Assistants were trained. A follow up was conducted which revealed that the Anesthesia Assistants were very helpful in providing surgical services but the course needed to be revised to include more content on anesthesia management. Thus, the Family Health Division and the National Health Training Center created a new competency based six-month anesthesia assistant course, which was piloted in Western Regional Hospital, Pokhara and the trainees were evaluated later. Based on the findings of the evaluation, the training curriculum was revised and endorsed. Patan Hospital, which is responsible for managing this course, has so far trained 24 Anesthesia Assistants (AAs). 1. Objectives of the Study Overall Objectives: 1. Assessment of the Anesthesia Assistant course an assessment of the trainees experience, inputs into the training, etc. 2. Assessment of the skills and knowledge of the Anesthesia Assistant an assessment of the output of the training 3. Assessment of the impact of the Anesthesia Assistant on Safe Motherhood service delivery an assessment of the outcome of the training. For e.g., reduction in referrals, percentage of increase in cesarean section deliveries, reduction in incidences of deaths, etc. 2. Methodology The study was conducted through the use of both quantitative and qualitative methods using on-site observations, self-administered tests, and, interviews with health service providers, and Hospital Management Committee Members, both formally and informally. A literature review of national and international documents related to non-physician Anesthesia Assistants was conducted prior to the data collection to provide input on the design of the study. Altogether data and information has been collected from 68 health service providers of different levels from 17 hospitals and 3 primary health care centers around the country. Simple descriptive statistical tools like frequency and percentage was used to analyze the data. The findings have been analyzed and presented in the study using both quantitative and qualitative measures as have been applicable. 3. Findings The findings of this study primarily portrays the services being provided by the Anesthesia Assistants trained in the competency based six months training course. The N for knowledge of the AAs is 13 while for the rest N is 11, unless specified otherwise. References to the three months trained AAs (N=9) are made only in areas, where it is appropriate. Overall a total of 22 AAs, combining the 3-month trained and the 6-month trained, were included in this study. M&M Associates 6

8 The AAs (N=22) are relatively young with the youngest being 21 years of age while the oldest is 47 years old.. While 14 (63.6%) AAs are male, the rest 8 (36.4%) female. Nine (40.91%) have received 3 months AA training; the remaining 13 (59.09%) have received 6 months AA training. The average years of service of AAs is 15 years. The designations of AAs seem to be uniformly distributed. While over one fourth (27.27%) of AAs are designated as Staff Nurse, five (22.73%) are Health Assistants, 5 (22.73%) are AHWs of whom 3 are senior AHWs, and 3 (13.64%) are ANMs. Approximately two third (63.6%) of AAs were found to be moderately satisfied while over one fourth were highly satisfied from the training. Most of the AAs considered that practical and operation theater experiences were very good while the theoretical portion of the training was considered to be very good by only over half (54.5%) of the respondents. Over half of the AAs (N=11) were very satisfied with the trainer and his/her efforts in training them in anesthesia during the training while the rest were moderately satisfied. However, since all the trainers were foreigners, language was a problem during the initial period of the training. Most of the AAs were impressed by the quality of materials distributed during the training. However, some AAs felt that lack of models, dummies and pictures were felt repeatedly during the training. Approximately three fourth (72.7%) of the participants said that the six months duration of the training was just right. The AAs suggested that the training should include more exposure on general anesthesia, complications related to anesthesia, and, regional blocks. Judging by the service statistics and interaction with the different respondents it was found that the overall client flow, particularly for CEOC services, in the health institutions have increased after the AAs have started providing anesthesia services. The doctors opined that the hospital services have become more complete and regular due to the availability of Anesthesia Assistants in the hospitals. The doctors also felt that the presence of AAs has considerably decreased their workload and tension during surgery. The impact is felt in the CEOC services because even the well to do people of the community trust the surgical services of the health institution rather than going to higher centers for delivery. Thus it can be inferred that the maternal and neonatal mortality has also gone down due to the life-saving services available in the districts. Despite having very favorable impressions of the training, the AAs faced some problems during the six months training. The medium of instruction in English language was a big hindrance in comprehending the theoretical portion of the training. Some logistical problems were faced when the training was non-residential. Also some of the AAs considered that the allowance provided during the training was inadequate in meeting the cost of residence, transport and other daily necessities. Another problem mentioned by the AAs was the lack of adequate dummies, dolls and pictures during the training. Lack or shortage of these materials created problems in applying the acquired knowledge and skills. A true/false (full marks 100) test administered on the AAs demonstrated that the AAs are highly knowledgeable on different issues of anesthesia that they were trained in. While M&M Associates 7

9 more than 50% of the AAs scored above 75 in the test, around 33% scored between and rest scored below 65. The average score of AAs was Most of the AAs, over 80%, were found to be competent in all aspects of providing spinal and intravenous anesthesia, while only around 40% of the AAs were found to be competent in providing general anesthesia under bag and mask or with intubation and paralysis. Due to non-practice of intubation and very few cases of general anesthesia, most of the AAs are losing the skills or will lose the skills in due course of time. Very few AAs were seen to be confident in managing intubations and general anesthesia under bag and mask. Thus some experts have expressed their views as to continue strengthening AA's skills in performing intubations just for the purpose of patient resuscitation and not necessarily for surgery. Of the eight hospitals sampled with the six month trained AAs, only three hospitals provide elective surgery facilities. With one hospital providing no surgical services, the rest seven hospitals provide 24-hour emergency surgery facilities. Some three fourth (9 out of 12) of the six month trained AAs are involved in surgeries performed in their hospital. Of the 9 AAs involved in surgeries, three of the AAs are on 24 hour duty with no replacements while the rest six are involved in surgery on a rotational basis. Of all the six month trained AAs interviewed, 58% provide service not only within the operation theater but also in other places inside the hospital. These AAs were observed to be a dynamic lot providing services in the wards, the OPD, emergency, and labor and delivery rooms. Some 25% of the AAs are also providing anesthesia services outside the hospital. Over 70% of AAs have faced complications during surgery which include hyper and hypo tension, cardiac arrest, respiratory failure, hemorrhage, post spinal headache, etc. Generally it is AAs responsibility to monitor and manage the complications during surgeries but it was found that most of the AAs inform the operating doctor, in case any major complication occurs, and ask for his/her help to stabilize the patient. However, there is no practice of maintaining records of complications in most of the hospitals. As regards the anesthesia technique used for LSCS, it was found that all AAs use spinal anesthesia. Spinal anesthesia was the most preferred technique for appendectomy. Most of the AAs administered GA under bag and mask for laparatomy. However at times, spinal combined with IV anesthesia was also used for laparatomy. IV anesthesia using ketamine was administered for incision and drainage and child's closed reduction fracture. Almost all the respondents said that IV anesthesia was administered for manual removal of placenta in their hospitals. Of the eleven hospitals that provided some data related to surgery, six were zonal hospitals while the rest five were district hospitals. The study team found that it was difficult to get consistent data related to the different kinds of surgeries that were being conducted in the hospitals. In the past eleven months between August 2003 and June 2004, from the partial (incomplete) data collected from the eleven hospitals, around 12,550 surgeries took place out of which around 2550 were LSCS cases. Of the rest, around 60% were minor surgeries. M&M Associates 8

10 In the six zonal hospitals, over the past year (read 11 months), around 11,200 surgeries were performed out of which around 4,480 were major surgeries while the rest were minor surgeries. Around 2,350 LSCS were performed in the zonal hospitals and the percentage of LSCS over total surgeries is around 21% while the percentage of LSCS over major surgeries comes to around 53%. In the five district hospitals, over the past year (read 11 months), around 1,350 surgeries were performed out of which around 540 were major surgeries while the rest were minor surgeries. Around 200 LSCS were performed in the district hospitals and the percentage of LSCS over total surgeries is around 15% while the percentage of LSCS over major surgeries comes to around 37%. Since on average around 40% of the surgical cases of the hospitals are LSCS cases, majority of the surgical services being provided by the hospitals are for Emergency Obstetric Care and thus it can be inferred that the surgical services of the hospitals have made a big impact on the reduction of maternal and neonatal mortality. The availability of the services of the AAs has made this possible in most hospitals. Around 55% of the AAs are highly satisfied from being a health service provider, around 36% were moderately satisfied, while one AA was indifferent. As regards to their satisfaction in being an anesthesia assistant, the responses were almost the same. Around 54% of all respondents were knowledgeable that they have a job description. However, only two respondents were able to provide copies of their job description. But all the AAs were unanimous on the issue that the new work of anesthesia that had been entrusted to them was not in their job description. The absence AAs severely affects the surgical services of all hospitals. The working relationship of most of the AAs with the doctors and their colleagues is cordial and they have formed a good team for the management of anesthesia services. However, the AAs currently not providing anesthesia services seem to have a somewhat strained relationship with the doctors. While most of the hospitals provide allowances to the doctors for the surgical services that they provide, only around 25% of the sampled hospitals are providing extra allowances to AAs for their services. All respondents, including the Hospital Management Committee Members, feel that the AAs should receive allowances for their services. Most of the AAs felt that at present they were receiving no opportunities to enhance their anesthesia skills and knowledge. The AAs feel that they need to receive refresher training regularly in order to update themselves on anesthesia and to reassess and revitalize their skills. All the respondents of the study were unanimous in their opinion that the AAs required a separate designation and that the Government should create a separate post with the title of Anesthesia Assistant, to work exclusively in the operation theater. The following were some of the enabling factors that motivated the AAs: The AAs mentioned that their esteem amongst their colleagues has increased after they received the AA training and started providing anesthesia services. M&M Associates 9

11 Most of the AAs have cordial relations with the doctors and their other colleagues in the hospital and they feel that their colleagues also help them in their work whenever there is a need. The doctors find the AAs to be skilled and entrust them with complete responsibilities in managing anesthesia during surgeries. The following were some of the factors that hindered the performances and functions of the AAs: The surgeons are not trusting on the skills of the AAs completely because of the lack of relevant information on the training and the skills acquired by the AAs. Lack of adequate anesthesia equipment in the hospitals cause problems in providing safe anesthesia services. Lack of surgeries in some hospitals is a big hindering factor to the AAs. Lack of supervision and monitoring of AAs. Most of the AAs are not provided with any kind of allowances for the work that they do in the Operation Theater. As regards to the number of AAs required per hospital, and in order to implement the 15- year National Safe Motherhood Plan ( ), based on the recommendations of the respondents and the current workload based on the service statistics, at least two AAs should be posted in each district hospital and three AAs in each zonal hospital. Thus in order to ensure that the 63 district hospitals mentioned in the 15-year plan are able to function as CEOC sites, a total of 126 anesthesia assistants are necessary. The anesthesia assistant training has contributed significantly in the provision of lifesaving surgical services, especially for CEOC, at district and zonal level hospitals thereby having a valuable impact in reducing maternal and neonatal mortality. The training is good in enhancing the knowledge and skills of AAs. The impact of the training was found to be very positive as surgeries were being performed regularly in most of the hospitals where the trainees are posted. Referrals from these hospitals to higher centers have declined to a large extent, especially for delivery related cases because most of the hospitals provide LSCS services. In turn, referrals from other centers to the hospitals for different services, particularly for CEOC services have increased and are gradually increasing. Overall, the six months anesthesia assistant training is found to be very good and has had a major impact on the CEOC services being provided by the hospitals sampled in the study. The following are some of the recommendations related to improving the AA training the AA services: The training needs to be institutionalized and conducted in Nepali. The training materials should be translated to Nepali. The trainer or another resource person should facilitate the transition of each trainee into his/her institution from training to service provision. The surgeons working with the AAs should be updated on the content of the training and the skills of the AAs. M&M Associates 10

12 The AAs should be periodically supported with resource materials and further training opportunities so as to maintain and enhance their skills. The training needs to incorporate a topic on basic maintenance of anesthesia equipment. The trainers should request and analyze information about the setting of OT and the equipment available in the trainee's hospital before the training. All equipment should be checked for completeness before sending to the hospitals. The job description of the AAs needs to be developed and their level of responsibility clearly spelt out. Record keeping of complications and surgery related data is weak and the practice needs to be started The AAs should continue the practice of maintaining anesthesia charts. HMG needs to introduce a separate position of Anesthesia Assistants in the health system. A system of network should be developed between the AAs and Physician Anesthetists working closest to their health center. The AA's intubating skills should be strengthened for the purpose of patient resuscitation. M&M Associates 11

13 A. Introduction The National Safe Motherhood Policy aims at increasing the availability and accessibility of quality comprehensive essential obstetric care (CEOC) at the fist level referral center (district or zonal hospital). The provision of safe anesthetic care is an essential element in ensuring the availability of quality surgical obstetrics 24 hours a day. Hence, in 1996, a three-month anesthesia assistant course was launched with financial support from WHO. The Department of Anesthesia of Bir Hospital was selected as a training site. This course continued up to year 2000, and approximately 50 Anesthesia Assistants were trained. A follow up was conducted with a few trainees and the findings suggested that physician specialist anesthetists were happy to have trained personnel assisting them in their work as one extra pair of hands. However, during this follow up study, the skills of the Anesthesia Assistants were not assessed. Nevertheless this follow up of the three-month training experience led the policy makers to realize the importance of revising the course. Therefore, in 2000, the Family Health Division decided to conduct a needs assessment to understand the capacity of the phase-one project-supported three CEOC sites in providing quality anesthetic care services (Baglung, Surkhet and Kailali). The findings suggested that all three hospitals had poor capacity to provide safe anesthetic care, mainly due to the lack of skilled anesthetic practitioners. Thus, in March 2000, FHD and the National Health Training Centre reviewed the existing three-month training course conducted at Bir Hospital. This led to the creation of a new competency based six-month anesthesia assistant course. This training was piloted in Western Regional Hospital, Pokhara and the trainees were evaluated later. Based on the findings of the evaluation, the training curriculum was revised and endorsed by National Health Training Center. The responsibility of conducting this course was given to Patan Hospital and the first six-month course was conducted in Since then, five batches of training have taken place at Patan Hospital and two batches have been trained at Tansen Hospital. Altogether 24 Anesthesia Assistants have been trained so far. 1. The Anesthesia Assistant Training in Nepal There is a general consensus that there is a desperate shortage of anesthetic skills outside a relatively small number of larger, regional institutions. Thus doctors working in zonal and district hospitals, who have surgical training, are rarely able to make use of their skills, and then only in a limited way. Effectively, their skills are useless and they are unable to fully and safely serve the needs of the local population. In particular, pregnant women and their babies are put at grave risk because of the lack of skilled, surgical interventions required for Safer Motherhood. Often patients are unable to undergo surgery unless they can afford both the time and money to travel to larger centers in Nepal or even India. Some patients requiring urgent surgery will simply be too unwell to travel further than their district hospital. Often patients are unable to undergo surgery unless they can afford both the time and money to travel to larger centers in Nepal or M&M Associates 12

14 even in India. Some patients requiring urgent surgery will simply be too unwell to travel further than their district hospital. The doctors in zonal and district hospitals have to be competent over a very wide range of medical specialties and administration. In this situation, it is not realistic to maintain the high levels of skill required to deliver the technical aspects of anesthesia practice. In addition, it is generally regarded as unsatisfactory to have one doctor acting as both surgeon and anesthetist. The lack of adequate manpower means that it is often not possible to have two doctors working on a single patient. Within the peripheral zonal and district hospital, in the context of anesthesia, the role of assistant is different from that required in a central hospital with specialist anesthetists. Centrally, the staffing levels are higher and there are dedicated specialists. At the district/zonal level, where the staffing levels are low, it is usual for there to be only one doctor attending to the obstetric and surgical emergencies. The doctor alone is unable to cope with many tasks necessary to perform and maintain anesthesia whilst carrying out surgery. Within this context an assistant must be competent in providing safe anesthesia services under the general supervision of the doctor. In the short to medium term future, there are two options. In the first option, anesthesia remains confined to few centers, under the control of a small number of specialists, leaving the rest of the country with either no anesthetic service or in the hands of untrained doctors and nurses trying to overcome this desperate situation. The Anesthesia Assistant Training is the result of the acceptance of the second option: paramedics and nurses be trained to provide safe anesthesia services particularly for obstetric cases. Training Content The AAT in Nepal is a competency based 6-month training program that stresses on learning by doing. Currently this course is designed to cover two weeks of theory and five and a half months of practical. The training course has the following learning objectives for each participant: 1. To be competent to assist in patient resuscitation. 2. To be competent to provide intermittent ketamine, spinal and general anesthesia. 3. To be competent in the peri-operative management of the patient. The following is the course content of the program: 1. Basic Sciences Anatomy Physiology Pharmacology 2. Anesthetic Equipment M&M Associates 13

15 3. Preparation for Surgery 4. Relaxant General Anesthesia Indications Anatomy of the airway Induction of anesthesia Control of the airway Maintenance of relaxant general anesthesia Reversal of relaxant GA 5. Intravenous Anesthesia Introduction Conduct of IVA 6. Spinal Anesthesia Introduction Basic sciences Conduct of spinal anesthesia 7. Anesthesia for Special Circumstances Anesthesia for maternity Anesthesia for emergency cases Anesthesia for pediatrics 8. Intra-operative Care of the Patient 9. Complications During Anesthesia Cardiovascular complications Respiratory complications Allergic reactions 10. Post-operative Care of the Patient 11. Recovery 12. Analgesia 13. Anesthesia and Medical Conditions Cardiovascular disease Respiratory diseases Nutritional disorders Chronic renal failure The participants of the training participate on an average 250 major cases of surgeries of which on an average 100 are LSCS, 100 cases are SAB and 50 cases are intubation. The knowledge of the trainees is evaluated three times during the course of the training. One test is administered before the start of the training program, one after the fourth month and the last at the end of the training program. M&M Associates 14

16 2. Literature Review of National and International Documents Related to Non-Physician Anesthesia Assistants Anesthesia has played a very vital role in development in the field of surgery but of late the lack of anesthesia care all over the world has been greatly experienced. Hence the need for a research to determine the levels of anesthesia care provided and its recognition worldwide. No research of this kind has been undertaken till date but the results can help in assessing the shortcomings in current practices and how anesthesia care can be improved. This report addresses similar studies of educational programs for nurses providing anesthesia care in various countries, the pros and cons of certified registered nurse anesthetists (CRNAs) and anesthesiologists and the condition of anesthesia care in some countries. It highlights the fact that although in many countries nurses have been providing anesthesia care and services, the government does not recognize their training. The history of anesthesia dates back to the 13 th century when a Spanish chemist, Lillius, distilled ether as a liquid. The continent of Europe is said to have been made more aware of the state of anesthesia by a Scottish obstetrician, Sir James Simpson in 1853 by the use of chloroform as an anesthetic for Queen Victoria's eighth delivery and Nurse Anesthesia was brought to the North American continent by a German Catholic nursing order that established hospitals along the railroads as they traveled west across the United States. Many ordinary nurses were trained by physicians to provide anesthesia care as health care reached out to distant stations of the world. 1 Various studies of the education programs for nurses providing anesthesia care have been taken from all over the world. These studies have pointed out the condition of anesthesia care in various countries. A study about the educational processes for nurses administering anesthesia care internationally came in 1991 in Oslo, Norway at the 3rd International Congress for Nurse Anesthetists. Although due to language barrier and distance, the information provided in this report was not comprehensive, it was a start to the first educational forum at the 4 th World Congress for Nurse Anesthetists in Paris, France in The International Federation of Nurse Anesthetists (IFNA) was chartered in June 1989 in which 11 countries were made members. During the Oslo meeting, educators who were elected to survey the educational process of nurses providing anesthesia care in countries of the world presented their results. The data were ranked into three educational groups of instructional structure provided by the individual institutions Primary, Secondary and Advanced. Questionnaires were sent to many countries all over the world to assess the anesthesia education levels and the data was compiled with the information sent by countries that responded to the questionnaire. A descriptive analysis was conducted by country grouping. Sixteen countries in Africa stated that nurses entering the anesthesia education 1 "An International Study of Educational Programs for Nurses Providing Anesthesia Care"-Journal of the American Anesthesia Association of Nurse Anesthetists, Vol. 62 No. 6, Dec. 1994, Pg "An International Study of Educational Programs for Nurses Providing Anesthesia Care"-Journal of the American Anesthesia Association of Nurse Anesthetists, Vol. 62 No. 6, Dec. 1994, Pg. 484 M&M Associates 15

17 program were prepared for patient care in a 3-year diploma nursing school. 3 Europe was addressing a standard for nursing education that would initiate a European License for registered Nurses instead of having each county provide individual licenses. 4 In the United States a national accrediting body, the Council on Accreditation of Nurse Anesthesia Education Program, accredited the anesthesia education programs. Accreditation was necessary to receive federal funding from the federal government. 5 In the United Kingdom, theatre nurses assisted physician anesthetists in anesthesia care. A certificate of anesthesia care was provided to nurses leaving the UK to practice anesthesia care outside the country however no organized program was presented. 6 It was found that countries such as Philippine Islands and Mexico were behind in providing this education to nurses. 7 Saudi Arabia and the United Arab Emirates employed nurse anesthetists who were educated in other countries such as Europe and Korea. 8 The report shows that the western world had longer training periods and more training institutes. Most countries had programs of two to three years duration in nurse anesthesia and the educational process generally required around two years of clinical nursing experience. In a study undertaken by an exploratory international survey between 1993 and 1996 where 107 countries were contacted via questionnaires, it was found that mostly nurses looked after anesthesia care and many of them performed certain essential functions with or without physician anesthetists in attendance. 9 Almost 60% reported that nurse anesthetists received two to three years of basic training. Only half the respondents claimed that continuing education programs in anesthesia were available in their countries. These programs were commonest in the European region and least available in the African region and the south East Asian region. The NCNAE (National Commission on Nurse Anesthesia Education) was implemented in 1989 due to a severe shortage of CRNAs (Certified Registered Nurse Anesthetists). Its responsibility was to scrutinize all aspects of nurse anesthesia educational programs. The commission's work and programs resulted in an increase in annual graduates from nurse anesthesia programs and 10 new programs were developed. 10 In 2001 an analysis of labor supply and demand for anesthesiologists since 1993 was taken. After studying data from the American Board of Anesthesiology the Department of General Anesthesiology, The Cleveland Clinic Foundation, Ohio found that the shortfall of 3 "An International Study of Educational Programs for Nurses Providing Anesthesia Care"-Journal of the American Anesthesia Association of Nurse Anesthetists, Vol. 62 No. 6, Dec. 1994, Pg "An International Study of Educational Programs for Nurses Providing Anesthesia Care"-Journal of the American Anesthesia Association of Nurse Anesthetists, Vol. 62 No. 6, Dec. 1994, Pg "An International Study of Educational Programs for Nurses Providing Anesthesia Care"-Journal of the American Anesthesia Association of Nurse Anesthetists, Vol. 62 No. 6, Dec. 1994, Pg "An International Study of Educational Programs for Nurses Providing Anesthesia Care"-Journal of the American Anesthesia Association of Nurse Anesthetists, Vol. 62 No. 6, Dec. 1994, Pg "An International Study of Educational Programs for Nurses Providing Anesthesia Care"-Journal of the American Anesthesia Association of Nurse Anesthetists, Vol. 62 No. 6, Dec "An International Study of Educational Programs for Nurses Providing Anesthesia Care"-Journal of the American Anesthesia Association of Nurse Anesthetists, Vol. 62 No. 6, Dec. 1994, Pg "Practice and education of nurse anesthetists" Bulletin of the World Health Organization, 1999, Pg "The National Commission on Nurse Anesthesia Education 10 years later Part 2" - Journal of the American Anesthesia Association of Nurse Anesthetists, Vol. 69 No. 6, Dec. 2001, Pg. 455 M&M Associates 16

18 anesthesiologists would continue through The shortage in 2002 was estimated at anesthesiologists and the number is expected to be by The subject of who can provide anesthesia care is a long debated one. Since the 1800s nurses have provided anesthesia service. Studies have shown that due to shortage of anesthesiologists in most countries the nurses' end up providing anesthesia care and very often the anesthesia education of the nurse is of a short duration or merely based on observation. The Texan Association of Nurse Anesthetists (TANA) undertook a study to asses the differential costs of preparing nurse anesthetists and anesthesiologists. On the basis of various data it was found that it cost approximately $635, 000 to prepare an anesthesiologist while the cost of preparing a CRNA in Texas was $59, 000. In other words 10 CRNAs could be prepared for the cost of one anesthesiologist in addition they could put in more years of service as professional nurses as compared to the anesthesiologist. 12 However it must be acknowledged that the nurse could never take the place of the physician Anesthesia care especially in many parts of Asia as well as many countries in Africa is lagging behind due to various reasons such as a lack of awareness of the subject, insufficient reference material and a lack of certified registered institutions providing nurse anesthesia education. 13 An example of the lack of awareness of anesthesia care is the case of Dr Michael Kavum of Uganda who after participating in a 2 month course where they were taught to keep their anesthesia safe but simple. He returned to his hospital with an enlightened perception of anesthesia. Mistakes such as the use of halothane without supplementing it with oxygen and use of 5% Thiopentone rather than 2.5% were rectified. One of the anesthesia assistance programs started in Mwanza, Tanzania by Dr Zutz is a 12-month curriculum, where the students are, for the most part, nurses who have had no previous anesthesia experience. 14 The emphasis is on basic care, which is limited due to shortage of facilities as well as personnel. While the general way to assess student progress is to give regular tests Dr Zutz takes on a more interactive option, which he recommends to others as well. In this teaching method he constructs cases that the students work on in small groups over the weekend and then present their cases on Mondays. 15 Asia is lagging behind in anesthesia care due to a shortage of manpower as many of its anesthesiologists go to other countries that are economically and politically more stable and provided better amenities for them in their work place as well as homes. 16 In a study that was conducted only 26.5% nurses reported that they had adequate knowledge of 11 An updated view of the national anesthesia personnel shortfall" Anesthesia Analgesia, 2003 Jan, Pg "Health educational costs, provider mix, and healthcare reform; A case in point nurse anesthetists and anesthesiologists"- Journal of the American Anesthesia Association of Nurse Anesthetists, Vol. 64 No. 1, Feb Pg "A Short Course in Anesthesia for Doctors in Rural Uganda" World anesthesia news, Vol. 2, No. 1, Personal Communication 15 Personal Communication 16 "Anesthesia Manpower Shortage in Asia Discussion" - World anesthesia news, Vol. 3, No. 1, 1999 M&M Associates 17

19 how to use and solve problems of anesthetic machines. 17 In Nepal, prior to 1956 there were no qualified anesthesiologists. Although today nurses are being trained to give anesthesia care and are working in hospitals, the Ministry of Health has not recognized their training. 18 Through the various studies that have been undertaken all over the world it is evident to see that anesthesia care has to an extent been neglected by governing bodies in countries all over the world. Today most health analysts agree that we have too many physicians, particularly specialists and the general overage of medical specialists would mean spending billions of dollars in educating them. 19 The future of nurse anesthesia practice and education depends heavily on government leadership in improving the organization and regulation of nursing and health services. 20 The shortage of anesthesiologists, as well as, the cost of preparing them has brought about a simple solution of training nurses to administer anesthesia keeping in mind that they are a cheap and effective option. Seeing as many nurses are already administering anesthesia and that they have been the major hands-on providers of anesthesia services since the late 1870s, 21 the focus should now be on building more educational institutes that recognize the anesthesia training administered to nurses. In developing more Certified Registered Nursing Programs the lack of man power in this field can be addressed. 17 "Anesthesia Manpower Shortage in Asia Discussion" - World anesthesia news, Vol. 3, No. 1, "Anesthesia in Nepal; Present and future aims" Topical Doctor, "Health educational costs, provider mix, and healthcare reform; A case in point nurse anesthetists and anesthesiologists"- Journal of the American Anesthesia Association of Nurse Anesthetists, Vol. 64 No. 1, Feb Pg "Practice and education of nurse anesthetists" Bulletin of the World Health Organization, 1999, Pg "Health educational costs, provider mix, and healthcare reform; A case in point nurse anesthetists and anesthesiologists"- Journal of the American Anesthesia Association of Nurse Anesthetists, Vol. 64 No. 1, Feb M&M Associates 18

20 3. Objectives of the Study The main objective of the study is to assess the quality of the anesthetic services provided by Anesthesia Assistants at the CEOC facilities. Following are the objectives of the study: Overall Objectives: 1. Assessment of the Anesthesia Assistant course an assessment of the trainees experience, inputs into the training, etc. 2. Assessment of the skills and knowledge of the Anesthesia Assistant an assessment of the output of the training 3. Assessment of the impact of the Anesthesia Assistant on Safe Motherhood service delivery an assessment of the outcome of to the training. For e.g., reduction in referrals, percentage of increase in C/S deliveries, reduction in incidences of deaths, etc. Specific Objectives: 1. To assess the level of competence of trained Anesthesia Assistants to provide safe anesthetic services at their workplace 2. To assess the capacity of the CEOC hospitals to provide quality AA services 3. To assess the enabling and hindering factors in providing safe anesthetic services 4. To assess the contribution of the provision of AAs to increased utilization of emergency obstetric care in these districts (i.e., what would have happened in their absence?) 5. To assess the quality, duration and appropriateness of the training process and sites and to make any recommendations for change 6. To estimate the number of AAs required to meet the National Safe Motherhood Plan and suggest a realistic training and supervision plan towards this including identification of training sites 7. To identify the nature of future support needed from FHD, NHTC and EDPs to meet the training and supervision plan 8. To recommend steps for further recognize and institutionalize AA training in Nepal M&M Associates 19